Senior Utilization MDS/MMQ Management Nurse RN - Western Massachusetts
Company: UnitedHealth Group
Location: Chicopee
Posted on: May 14, 2022
Job Description:
Combine two of the fastest-growing fields on the planet with a
culture of performance, collaboration and opportunity and this is
what you get. Leading edge technology in an industry that's
improving the lives of millions. Here, innovation isn't about
another gadget, it's about making health care data available
wherever and whenever people need it, safely and reliably. There's
no room for error. Join us and start doing your life's best
work.(sm)If you are located in the Massachusetts area, you will
have the flexibility to telecommute* as you take on some tough
challenges. Travel within territory 100% of the time and assist
when needed in the state of Massachusetts during audits (9 out of
12 months of the year) (Audits will be conducted onsite removed
from patient care areas); the other 3 out of 12 months you will be
home.Primary Responsibilities:
- Audit entire medical record for accuracy of the coding on the
MMQ to support payment to the nursing facility
- Answer patient questions regarding care (medication, treatment)
and benefits
- Discuss Patient Care specifics with peers or providers in
overall patient care and benefits
- Leverage appropriate clinical terminology when communicating
with physicians and other medical professionals
- Communicate clinical findings and present rationale for
decisions to medical professionals and members at the appropriate
level for understanding
- Advocate with physicians and others for appropriate decisions
(e.g. patient level of care changes) regarding patient betterment
(e.g. care and service coverage, safety)
- Comply with HIPAA guidelines related to Personal Health
Information (PHI) when communicating with others
- Leverage experience and understanding of disease pathology to
review chart/clinical information, ask appropriate questions, and
identify appropriate course of care in a given situation
- Perform assessment that includes a review of current and prior
patient conditions, documents, and evaluations, and relevant social
and economic situations to identify patients' needs
- Research and identify information needed to perform assessment,
respond to questions, or make recommendations
- Interview patients/family members or other providers to obtain
information needed to make decisions
- Identify inconsistencies or illogical information in patient
responses, provider orders or patient history information and take
appropriate action
- Apply knowledge of pharmacology and clinical treatment protocol
to determine appropriateness of care and instruct patients as
needed
- Work collaboratively with peers/team members and other levels
or segments within Optum, UHC, or UBH (eg. Case Managers, Field
Care Advocates) to identify appropriate course of action (eg.
Appropriate care, follow up course of action, make referral)
-You'll be rewarded and recognized for your performance in an
environment that will challenge you and give you clear direction on
what it takes to succeed in your role as well as provide
development for other roles you may be interested in. -Required
Qualifications:
- Undergraduate degree or 4+ years of equivalent nursing
experience
- Current unrestricted RN nurse license in Massachusetts
- 1+ years of long-term care MMQ, MDS, or management experience
(in long-term care) experience
- Experience assessing, reviewing and applying criteria (eg.
Milliman guidelines, CMS criteria, medical policy)
- Knowledge of healthcare insurance industry products (eg. HMO,
PPO, ASO)
- Knowledge of Medicaid and Medicare benefit products including
applicable state regulations
- Demonstrate knowledge of process flow of UM including prior
authorization, concurrent authorization, and/or clinical appeal and
guidance reviews
- Ability to travel within territory 100% of the time and assist
when needed in the state of Massachusetts during audits (9 out of
12 months of the year) (Audits will be conducted onsite removed
from patient care areas); the other 3 out of 12 months you will
primarily be home-based with remote work -including July and
December.
- Full COVID-19 vaccination is an essential requirement of this
role. Candidates located in states that mandate COVID-19 booster
doses must also comply with those state requirements. UnitedHealth
Group will adhere to all federal, state and local regulations as
well as all client requirements and will obtain necessary proof of
vaccination, and boosters when applicable, prior to employment to
ensure compliancePreferred Qualifications:
- Demonstrate knowledge of applicable area of specialization
- Demonstrate knowledge of computer functionality, navigation,
and software applicationsTo protect the health and safety of our
workforce, patients and communities we serve, UnitedHealth Group
and its affiliate companies require all employees to disclose
COVID-19 vaccination status prior to beginning employment. In
addition, some roles and locations require full COVID-19
vaccination, including boosters, as an essential job function.
UnitedHealth Group adheres to all federal, state and local COVID-19
vaccination regulations as well as all client COVID-19 vaccination
requirements and will obtain the necessary information from
candidates prior to employment to ensure compliance. Candidates
must be able to perform all essential job functions with or without
reasonable accommodation. Failure to meet the vaccination
requirement may result in rescission of an employment offer or
termination of employment.Careers with Optum. Here's the idea. We
built an entire organization around one giant objective; make
health care work better for everyone. So when it comes to how we
use the world's large accumulation of health-related information,
or guide health and lifestyle choices or manage pharmacy benefits
for millions, our first goal is to leap beyond the status quo and
uncover new ways to serve. Optum, part of the UnitedHealth Group
family of businesses, brings together some of the greatest minds
and most advanced ideas on where health care has to go in order to
reach its fullest potential. For you, that means working on high
performance teams against sophisticated challenges that matter.
Optum, incredible ideas in one incredible company and a singular
opportunity to do your life's best work.(sm)*All Telecommuters will
be required to adhere to UnitedHealth Group's Telecommuter
Policy.Diversity creates a healthier atmosphere: UnitedHealth Group
is an Equal Employment Opportunity/Affirmative Action employer and
all qualified applicants will receive consideration for employment
without regard to race, color, religion, sex, age, national origin,
protected veteran status, disability status, sexual orientation,
gender identity or expression, marital status, genetic information,
or any other characteristic protected by law.UnitedHealth Group is
a drug-free workplace. Candidates are required to pass a drug test
before beginning employment.
Keywords: UnitedHealth Group, Chicopee , Senior Utilization MDS/MMQ Management Nurse RN - Western Massachusetts, Executive , Chicopee, Massachusetts
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